Job Description

At Memorial Hermann, were about creating exceptional experiences for both our patients and our employees. Our goal is to provide opportunities for our diverse employee population that develop and grow careers in a team-oriented environment focused on patient care.

Every employee, at every level, begins their journey at Memorial Hermann learning about the history of the organization and its established culture built on trust and integrity. Our employees drive this culture, and we want you to be a part of it.

Job Summary

Responsible for providing care management services and support to an assigned population with the purpose of improving health outcomes via a coordinated approach. The Care Manager II works in collaboration and continuous partnership with patients and their family members, as well as clinic, hospital, post-acute and insurance company partners, along with community resources, to achieve the desired outcomes. Using a defined process to identify patients/members at risk for poor outcomes, the Care Manager II establishes care plans and goals, and coordinates care and services throughout the continuum of care for patients assigned to the care management programs with the goal of enhancing patient health and well-being, improving adherence to health programs, and reducing health care costs.

Must be highly collaborative with strong customer service skills and be able to demonstrate the ability to actively engage patients in positive relationships. Must also be able to demonstrate the knowledge and skills necessary to provide care management services appropriate to the patient/member being served.

Job Description

Minimum Qualifications

Education: Registered Nurse (RN) or Social Worker (LMSW)

Licenses/Certifications: Registered Nurse (RN) or Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW) with active license in the state of Texas

Experience / Knowledge / Skills:

* Experience in care/case management, chronic disease management or population health preferred
* At least two (2) years of experience in care coordination and planning or other related area
* Experience working in interdisciplinary teams
* Excellent computer skills
* Effective oral and written communication skills
* Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of we advance health through innovation, accountability, empowerment, collaboration, compassion and results while ensuring One Memorial Hermann.

Principal Accountabilities

* Provides primary care management interventions to identified members enrolled in the Health Management programs.
* In conjunction with payers and health care teams across the continuum, identify members at risk for poor outcomes, or experiencing poor coordination of services, who would benefit from more intensive follow-up and care coordination.
* Coordinates in conjunction with providers and health plans, a comprehensive plan of care for the high-risk, high-utilizing population, and collaborates with clinical staff and the patient/family in the development and execution of the plan of care, and achievement of goals.
* Provides proactive outreach to members to include telephonic, internet, or face-to-face encounters.
* Works cohesively with other health management disciplines to assist members in problem-solving potential issues related to financial and psychological barriers, as well as problems with the overall system of care.
* Increases continuity of care by managing and facilitating relationships with post-acute providers, physicians, and community resources.
* Manages effective transitions in care by facilitating warm hand-offs and closure of gaps in care.
* Promotes timely access to appropriate care and promote effective and efficient utilization of clinical resources.
* Promotes adherence to an established plan of care.
* Increases utilization of primary care services within an established network.
* Reduces emergency room utilization and hospital readmissions via a comprehensive approach.
* Increases patients ability for self-management and shared decision-making.
* Increases comprehension and health literacy through appropriate education.
* Provides medication management, including comprehensive medication review and make recommendations to primary care provider for medication changes based on evidence-based protocols.
* Provides chronic disease and self-management education and support.
* Connects patients to relevant community resources necessary to support health and well-being.
* Coordinates warm hand-off to members primary care provider upon successful completion of the program.
* Directs and participates in the development and implementation of member care policies and protocols in order to provide advice and guidance in handling special cases or member needs.
* Makes referrals to other Health Management team members as necessary to promote effective care coordination services.
* Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
* Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
* Other duties as assigned.